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Based on observation, staff interview, and review of policies and procedures, the facility failed to safeguard paper copies of patient records to ensure confidential information was securely stored and not accessable to unauthorized individuals. The findings were:

Observation on 11/1/11 at 2 PM and again on 11/3/11 at 10 AM revealed a large storage room on the first floor east. Entry into the room was available from two locations: from the medical records department and from a corridor door located on the other side of the large storage room. In addition, the large storage room was separated into two areas: a small caged area and a much larger storage area. The caged areas were accessible from the medical records department, and access to the larger area was directly through the corridor door. Only medical records were stored in the small caged area; however, at least 50 boxes containing paper copies of closed medical records, as well as other supplies and radiology materials, were stored in the larger area. A locked door in the cage separated the two areas.

Interview with the health information manager on 11/1/11 at 2 PM revealed the door from the corridor was always locked and access could only be gained by using a master key. Further interview and review of the policy, "Accessibility to the Medical Record and the HIM Department", revised 12/2/11, revealed several departments had access to the medical records storage area including medical records, radiology, nursing, administration, security and maintenance. Each of these departments had a "master key" for access into the large storage area. Depending upon circumstances, the time of day, work schedule, etc., a department's master key was available to more than one employee of that department during and after business hours. However, according to the policy, "Accessibility to the Medical Record and the HIM Department", revised 12/2/11, access after hours in emergencies was limited to administration, nursing and engineering employees.

Based on observation, staff interview, and review of policies and procedures, the facility failed to safeguard paper copies of patient records to ensure confidential information was securely stored and not accessable to unauthorized individuals. The findings were:

Observation on 11/1/11 at 2 PM and again on 11/3/11 at 10 AM revealed a large storage room on the first floor east. Entry into the room was available from two locations: from the medical records department and from a corridor door located on the other side of the large storage room. In addition, the large storage room was separated into two areas: a small caged area and a much larger storage area. The caged areas were accessible from the medical records department, and access to the larger area was directly through the corridor door. Only medical records were stored in the small caged area; however, at least 50 boxes containing paper copies of closed medical records, as well as other supplies and radiology materials, were stored in the larger area. A locked door in the cage separated the two areas.

Interview with the health information manager on 11/1/11 at 2 PM revealed the door from the corridor was always locked and access could only be gained by using a master key. Further interview and review of the policy, "Accessibility to the Medical Record and the HIM Department", revised 12/2/11, revealed several departments had access to the medical records storage area including medical records, radiology, nursing, administration, security and maintenance. Each of these departments had a "master key" for access into the large storage area. Depending upon circumstances, the time of day, work schedule, etc., a department's master key was available to more than one employee of that department during and after business hours. However, according to the policy, "Accessibility to the Medical Record and the HIM Department", revised 12/2/11, access after hours in emergencies was limited to administration, nursing and engineering employees.

Based on observation, staff interview, and medical record review, the facility failed to provide consistent monitoring for 3 of 3 patients (#5, #6, #10) in the Behaviorial Health Services (BHS) unit who were assessed as needing close observation. In addition, the facility failed to ensure a safe environment for patient #5 who was at risk for self injury. The findings were:

Interview on 10/31/11 at 4 PM with RN #1, who was the nurse on duty in the BHS unit revealed patients #5, #6, and #10 required close monitoring. The RN stated staff were to observe the patients every fifteen minutes and document the observations on a form called the "Behavioral Health Daily Graphics Sheet" (BHDGS). The following concerns were identified:

1. Observation in the BHS unit on 10/31/11 from 3:35 PM to 4:50 PM revealed the bathroom flush valves and plumbing hardware on the sinks in all of the patients' rooms could potentially be used in a harmful manner by patients who were assessed as high suicidal risks. Interview with the director of the unit on 11/1/11 at 3:15 PM revealed he had identified this as one of the areas that made the unit environmentally unsafe for patients at risk for self injury. He stated replacement hardware was ordered and measures to ensure safety had been implemented until the existing parts could be replaced. He further stated the safety measures included surveillance and close monitoring of the patients. Review of the 10/29/11 multidisciplinary treatment plan for patient #5 showed the "reason for admission" was "danger to self." Review of the care plan showed interventions included monitoring to evaluate, maintain and assess safety issues. However, review of the 10/31/11 BHDGS for the patient showed documentation from 1:30 PM to 3 PM (one and a half hours) was lacking.

2. Review of the 10/31/11 BHDGS for patient #6 showed staff determined the patient needed to be monitored every fifteen minutes due to "Clinical Institute Withdrawal Assessment" (CIWA) precautions. Further review showed documentation was lacking from 1:00 PM to 2:45 PM (one hour and forty-five minutes).

3. Review of the 10/31/11BHDGS for patient #10 showed staff determined the patient needed to be monitored every fifteen minutes due to CIWA precautions. Further review showed the lack of documentation from 11:45 AM to 3 PM (three hours and fifteen minutes).

4. Interview with the director on 11/1/11 at 3:30 PM revealed the facility had not developed a policy and procedure regarding when to initiate the BHDGS protocol and how to complete it, but the expectation was that the patient was to be observed every fifteen minutes and the observation should be documented. He further stated incomplete documentation on the BHDGS for patients #5, #6 and #10 was not an acceptable practice.

Based on observation, patient and staff interviews, medical record review, and review of policies and procedures, the facility failed to ensure medications were administered appropriately for 1 of 19 sample patients (#2) in the facility during the survey. The findings were:

During an interview with patient #2 on 10/31/11 at 3:03 PM, a bottle of "Pain Wizard" was observed on the patient's overbed table. Review of the manufacturer's label (the only label on the bottle) showed it contained the medications capsaicin, menthol, and camphor. The patient stated s/he applied the cream daily on his/her left wrist for arthritis pain from an old fracture. The patient's hand was swollen and the wrist and forearm were wrapped; the patient further stated the wrist had been re-fractured in a recent fall and the cream helped control that pain, too.
Interview with RN #2, who was caring for the patient on 10/31/11 at 3:15 PM revealed she was unaware the bottle contained medications. She stated she thought the bottle was only skin softening lotion. At 3:16 PM RN #3, the unit manager, stated she was also unaware the medication was at the patient's bedside. The unit manager stated a physician's order was required before medications could be left at the bedside. After reviewing the medical record, the unit manager confirmed there was no order for self-administration of "Pain Wizard." Additionally, according to the facility's policy and procedure, "Medications Left at Patient Bedside," Number PC 77, last revised June 2011, the following guidelines were not met:
a. "Medications will not be left at the patient's bedside...other than: Topical preparations for administration by nursing personnel or physicians.
b. All orders will be screened by Pharmacy personnel and will be reviewed for appropriateness.
c. Medications meeting the criteria will be labeled [by pharmacy] appropriately and sent to nursing units for delivery to patient's rooms.
d. All self-medication doses must be recorded."

Based on observation, staff interview and review of policies and procedures, the facility failed to safeguard the confidentiality of health information by restricting access to medical records to only those employees involved in patient care, quality assessment and utilization review, and health information management. The findings were:

Observation on 11/1/11 at 2 PM and again on 11/3/11 at 10 AM revealed a large storage room on the first floor east. Entry into the room was available from two locations: from the medical records department and from a corridor door located on the other side of the large storage room. In addition, the large storage room was separated into two areas: a small caged area and a much larger storage area. The caged areas were accessible from the medical records department, and access to the larger area was directly through the corridor door. Only medical records were stored in the small caged area; however, at least 50 boxes containing paper copies of closed medical records, as well as other supplies and radiology materials, were stored in the larger area. A locked door in the cage separated the two areas.

Interview with the health information manager on 11/1/11 at 2 PM revealed the door from the corridor was always locked and access could only be gained by using a master key. Further interview and review of the policy, "Accessibility to the Medical Record and the HIM Department", revised 12/2/11, revealed several departments had access to the medical records storage area including medical records, radiology, nursing, administration, security and maintenance. Each of these departments had a "master key" for access into the large storage area. Depending upon circumstances, the time of day, work schedule, etc., a department's master key was available to more than one employee of that department during and after business hours. However, according to the policy, "Accessibility to the Medical Record and the HIM Department", revised 12/2/11, access after hours in emergencies was limited to administration, nursing and engineering employees.

Based on observation, staff interview, and review of quality assurance data, information from the CDC, and policies and procedures, the facility failed to develop, implement, and evaluate a hospital-wide infection control program that utilized real-time data. In addition, the facility failed to develop policies and procedures to mitigate risks contributing to healthcare-associated infections potentially transmitted by glucometers. Finally, the facility failed to ensure the cleanliness of devices used in medication administration. The findings were:

1. Interview with the infection control practitioner (ICP) and review of quality assurance data on 11/3/11 at 9:45 AM revealed the infection control committee met quarterly but reviewed data that was several months old. Perusal of the graphs produced by the ICP showed the latest data available for review at the next infection control meeting in November was from June 2011. Although there was a mechanism in place for notifying the ICP if an infectious outbreak occurred, there was no evidence real-time data would be available for review by the committee. During the interview, the ICP confirmed the lack of real-time data.

2. On 10/31/11 at 3:04 PM RN #4, a surgical nurse, stated staff were instructed to clean the glucometer with alcohol wipes per the manufacturer's recommendation. On 11/2/11 at 11:20 AM an unidentified RN was observed demonstrating the use of alcohol wipes to clean the glucometer after patient use. Both that RN and the director of surgical services revealed the surgical and recovery nursing staff used alcohol to clean the glucometer per the manufacturer's recommendation.
Review of the facility's policy and procedure entitled "Whole Blood Glucose Testing by Nursing Personnel," last revised June 2011, confirmed staff were to clean the glucometer with an alcohol wipe. Review of undated information from the CDC (provided by the facility) showed the following: "If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents." However, review of the CDC publication "Guideline for Disinfection and Sterilization in Healthcare Facilities", 2008, revealed the CDC does not recommend the use of alcohol to disinfect equipment when blood borne pathogens, such as hepatitis viruses, are a concern. The Association for Professionals in Infection Control & Epidemiology (APIC) recommendations for disinfecting point-of-care devices are published in the American Journal of Infection Control, April 2010. The APIC guideline recommends glucometers be disinfected with a dilute bleach solution or an Environmental Protection Agency (EPA)-registered disinfectant effective against hepatitis and human immunodeficiency viruses (HIV). Alcohol is not an EPA-registered disinfectant for blood borne pathogens. Both CDC and APIC further recommend that if a point-of-care device, such as a glucometer, cannot be effectively disinfected, then it should not be used to test multiple patients.

3. Observation in the medication room on the medical unit at 2:50 PM on 10/31/11 showed two clear glass mortars and pestles (devices for crushing/grinding medications) placed on a paper towel underneath the towel dispenser next to the handwashing sink. One mortar dish had been placed upside down and the other right side up; both were heavily covered with water spots. An additional observation on 11/3/11 at 8:30 AM revealed both devices remained in the same place. At that time the unit manager, RN #3, stated the devices were still used to crush medications and that they were washed after use. She verified the water spots on the devices and confirmed they should not be placed or stored under the towels where they could be contaminated.

Based on medical record review and staff interview, the facility failed to include documentation in the medical record that a list of home health agencies (HHAs) and/or SNFs was given to 2 of 2 sample patients (#11, #24) who required home health or SNF services. The findings were:

Review of medical records showed patient #11 was admitted on 10/26/11 and patient #24 was admitted on 10/12/11. Further review showed patient #11 would require home health services on discharge, and patient #24 was transferred to a SNF on 10/18/11. However, there was no documentation in either record that the patient had been given a list of the HHAs and SNFs. During an interview on 11/3/11 at 9:00 AM, the discharge planner stated that, although she had a list of HHAs and SNFs, she never documented in any patient's record that the patient had been given the list.

Based on staff interview and medical record review, the facility failed to ensure the discharge plans for 3 of 3 sample patients (#15, #16, #24) identified that the hospital had a disclosable financial interest in the skilled nursing facility (SNF) to which the patients were discharged. The findings were:

According to the medical records, patients #15, #16, and #24 were discharged to the hospital's extended care facility (ECF, a SNF). Review of the discharge plans showed no evidence the patients were informed prior to their discharge that the hospital owned the facility. During an interview on 11/3/11 at 9 AM, the discharge planner stated she did not inform patients that the hospital had a disclosable financial interest in the ECF.